UnitedHealthcare Prior (Rx) Authorization Form

Updated January 24, 2022

UnitedHealthcare prior authorization form is used by physicians in the instances they need to prescribe a medication that isn’t on the preferred drug list (PDL). Person’s covered under a UnitedHealthcare Community Plan (UHC) have access to a wide range of prescription medication. The purpose of this form is to demonstrate medical justification for prescribing the drug in question when other drugs on the PDL might serve the same purpose. The form should be submitted to UHC where they will review the physician’s medical reasoning and either approve or deny the prescription. If the request is denied, the patient may choose to pay for the drug out of pocket or ask the physician to prescribe a similar drug from the PDL.

Form can be faxed to: 1 (866) 940-7328

Phone number: 1 (800) 310-6826

Preferred Drug List

How to Write

Step 1 – Enter today’s date at the top of the page.

Step 2 – “Section A” must be completed with the patient’s information. Include the patient’s full name, member ID, address, phone number, DOB, allergies, primary insurance, policy number, and group number.

Step 3 – Select the “NEW” box if the medication has not been prescribed before or select the “CONTINUATION” box if this is a renewal request. If the second box was checked, enter the start date. If the patient is currently hospitalized, select “YES” otherwise select “NO”.

Step 4 – In the “Physician Information” section, enter the physician’s full name, address, phone number, fax number, NPI number, specialty, and office contact name.

Step 5 – Under “Medical Information”, enter the name of the requested drug, the strength, and the directions of use. Be sure to include the diagnosis and the appropriate ICD codes.

Step 6 – If the patient is pregnant, you must disclose this information and include their due date.

Step 7 – Next, a space is provided for the physician to include their medical reasoning as to why this particular drug must be prescribed over other medication options.

Step 8 – Under “Other Medications Tried”, enter the name, strength, directions, dates of therapy, and reason for discontinuation of all medications that were previously prescribed to the patient to treat their condition.